SWOT Analysis of Dental Health Workforce in India: A Dental alarm

Context: India faces an acute shortage of health personnel. Together with inequalities in distribution of health workers, dental health workers also become a part contributing to it impeding the progress towards achievement of the Millennium Development Goals. Aim: To assess dental health-workforce distribution, identify inequalities in dental health-workers provision and report the impact of this mal distribution in India. Materials and Methods: Situational analysis done by using the primary data from the records of Dental Council of India. Results: In India, 0.088% of dental health worker per 1000 population exists. Inequalities in the distribution of dentists exist in India. Certain states are experiencing an acute shortage of dental health personnel whereas certain cities are over fledged with dentists like Karnataka, Maharastra, Tamilnadu being states with high concentration & Jharkhand, Rajasthan, Uttaranchal being the least. Conclusion: Although the production of health workers has expanded greatly in recent years by increase in number of dental colleges the problems of imbalances in their distribution persist. In the race of increasing dentist population ratio in total, inequitable distribution of appropriately trained, motivated and supported dentists gives a mere feel of saturation in jobs making youngsters to not to choose dentistry as a career giving an alarm.

In developing countries, health workers play a central role in providing the appropriate management of all aspects of the health system despite the availability of effective interventions for many health problems [1]. India is a conglomeration of states with diverse levels of socioeconomic status, governance, health systems and health situations. As elsewhere, India also has shortages and mal distribution within its health workforce that have contributed to inequities in health outcomes [2]. India’s health workforce is a combination of both registered, formal healthcare providers and informal practitioners, the latter being the first point of contact for a large proportion of the population [2,3]. Added to it, Oral health policy in India is still in an Infant stage finding its way among the general health sector.

According to the 2006, World Health Report, India had 0.60% doctors, 0.80% nurses, 0.47% midwives, 0.06% dentists and 0.56% pharmacists respectively per 1000 population indicating acute shortage of dentists [4].

In addition to the known shortage, there is a common perception that large in-country inequalities exist in their distribution [2]. There have been efforts to increase the health workforce production to meet demand. However, these efforts have been hampered by increases in factors such as population size, purchasing power for health services within communities, life expectancy and the prevalence of non communicable diseases and other chronic conditions [1]. To date, the evidence to support this proposition has been limited, owing to a lack of reliable disaggregated data at the country & state level [2].

Data regarding dental surgeons registered with the central/ state dental councils was obtained from the Indian Ministry of Statistics and Programme Implementation’s 2011 report on Health and Family Welfare [5]. In addition, national and state data on the number of dental educational institutions as well as the number of admitted students were extracted from the Dental Council of India (DCI) databases [6]. Data regarding Public health dentists were obtained from the Indian Association of Public Health Dentistry information centre. Densities of health workers were calculated from the workforce data described above and census data on populations [2,7].

[Table/Fig-1] shows the absolute numbers and category-wise density (per 1000 population) of dentists at national and state levels. In 2009, India had 104603 dentists. There were gross inequalities in the availability of these health workers at the sub national level.

Review of the available data from [Table/Fig-2] on training dental students highlights three important developments. First is the recent rapid expansion in the training capacity of dentists. Between 1991 and 2013, the number of admissions to dental institutions expanded from 3100 to 23 800, i.e. by 66.8%[6]. There were clear inequalities in the distribution of these training institutions among states. Although the Empowered Action Group states account for almost half of the country’s population, they house approximately a quarter of the dental institutes [2].

Second, there has been a notable increase in the private sector’s involvement in Dental education. Before 1991, there were only 49 dental colleges, of which 23 (47%) were government owned. As of 2013, 246 new dental institutions recognized or approved by the DCI have been added to the existing list, of which almost all (229) are in the private sector [2,6]. Third, despite the consistent increase in dentist’s production, posts in public health sectors/government are still questionable.

Intra state differences in dentist’s availability, which may be associated with the urban-rural divide and corresponding economic disparities, could not be assessed owing to lack of access to district-level data. But, we could get data of public health dentist’s distribution state wise for assessment. [Table/Fig-3] shows an inter-state inequality among public health dentists from the data.

There was a positive correlation between the number of dental institutions and density of dentists (Spearman’s rho=0.353; p=0.116), implying that the scarcity of dentists in other areas.

As India strives to achieve universal health coverage, improvement in oral health care delivery with skilled and motivated dental health workforce is necessary. Human resource shortages hinder scale up of health services and limit the capacity to absorb additional financial resources [8]. A clear understanding of the dental health-workforce situation is very critical to develop effective policies. And such an effort to draft or recommend the policy still striving to show the importance of oral health in the main stream and failed to correct the increasing mal distribution of the workforce [9].

In the past two decades, there has been drastic progress in increasing the training capacity [9,10]. This review shows that key finding regarding workforce production is the increase in training capacity because of the growth in private sector involvement in dental education. This trend seems likely to increase, since incentives and regulation relaxations have been introduced to encourage private investment in dental education.

The primary data used in this review are the numbers of dental health personnel registered with the Dental Council of India & Dental Public Health Association and therefore have several limitations. These councils do not maintain live registers, except for doctors in Delhi. The information they provide may be inaccurate owing to non adjustment for deaths, migrations and retirements, or double counting of workers registered in more than one state. Furthermore, not all state councils follow the same procedure for registration, which may compromise direct comparisons. Data for dentists in some states (e.g. north-east India) are not available because there is no state-specific professional councils [7].

In spite of these limitations, this review is an attempt to highlight some key issues that the Government of India and development partners should consider when addressing the health human resource crisis. There is gross inadequacy in availability of the current stock of dentists [9–11] & public health dentist’s and significant inequalities in their distribution between the different states. Poorly performing states, in terms of health outcomes, have a greater shortfall in the number of dentists.

Opportunity: These shortages highlight the need to develop and implement high quality, evidence-based workforce plans, especially in the poorest and most fragile states. Similar to ROME (Reorientation of Medical Education), measures can be taken to utilize, motivate existing interns to work in the rural setting by adopting PHCs where it is not started and where it is functioning re-strengthening the centres by functional measures can be done [9].

While production of dental health workers in India has increased in recent years, it is at the cost of increased privatization of dental education. The rapid growth in the production of dentists has not helped to address the public health system. Further, the problems of imbalances in the distribution of these health personnel persist, with certain states remaining at a disadvantage. These findings suggest that mere increase in production is unlikely to resolve the issues related to dental health worker availability & distribution.

Growth of private sector in increasing the training of dental workforce cannot be ruled out but a proper needs assessment has to be done or else a mere feel of saturation in jobs may make youngsters to not to choose dentistry as a career. Hence, it requires a proper planning for a policy to provide oral health for all. Human resource planning and utilization should be based on the aim for sustained development along with a system of monitoring and evaluation of programs.

A recent symposium held on implementation of oral health policy action plan - phase I in Mangalore, Karnataka recommended including Public health dentists in every district planning committee to do the needs assessment & provide primary health care [13]. Hence, it becomes important for a public health dentist to know the availability & distribution of the dental health workforce and to address the existing inequality. The problem of unequal distribution cannot be addressed without a political will. Hence, a sustained and innovative action to address India’s current dental health workforce crisis is further recommended.

Production of Dental Graduates & Post Graduates in all the specialities are increasing and it is observed that many are facing the job problems & a recent report in Times of India stated seats in many dental colleges are not filled. But the scenario on national level is different and shows uneven distribution of Dental Health Workforce. India as such lacks a national oral health policy. Hence, this situational analysis can be utilized by policy makers in order to overcome the gap.

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